On Injuries of the Head Affecting the Brain

On Injuries of the Head affecting the Brain. By G. J. Guthrie, F.R.S. Surgeon to the Westminster Hospital, and to the Royal Westminster Ophthalmic Hospital, &c. &c. 4 to. pp. 155. London, 1842. T hese observations are the substance of the Lectures delivered in the heatre of the Royal College of Surgeons in the Spring of 1841. They p?mprise and present the results of Mr. Guthrie's experience during the er?nsular war, and form a valuable addition to our existing; surgical literature.

Head affecting the Brain.By G. J.Guthrie, F.R.S. Surgeon to the Westminster Hospital, and to the Royal Westminster Ophthalmic Hospital, &c.&c. 4 to.pp.155.London, 1842.T hese observations are the substance of the Lectures delivered in the heatre of the Royal College of Surgeons in the Spring of 1841.They p?mprise and present the results of Mr. Guthrie's experience during the er?nsular war, and form a valuable addition to our existing; surgical lite- rature. of ^lere *s no division into sections or chapters, nor does the arrangement , the lectures appear to have been a precise one.Whatever advantage Us may offer the lecturer, and we question if it has any, it certainly is of ^ one to the reader, still less to the reviewer.We will not therefore at- jt10^ Present a strict analysis of the work, but select what portions of ' *1 ber facts or doctrine, are either novel or important.of ?^u^lrie commences by pointing out the uncertainty of the symptoms Aftln^UneS ^ie ^ieac^ an(^ the equal uncertainty of their diagnosis.1 ?r?^serving, what is well known, that some persons will survive the Ss of considerable portions of the brain, while others will sink under 1 slighter injuries, Mr. Guthrie remarks :? cc Tli fr je result of my experience on this point is, that brain is more rarely lost that* fore art of the head with impunity, than from the middle part; and p .a ^cture of the skull, with even the lodgement of a foreign body, and a eon !?n tbe bone the brain, may be sometimes borne without any great in- a s \Ci?lerlce the back part.During the war with the United States in 1814, the? iCr *n ^ana^a was struck by a ball which lodged in the posterior part of Tw >i tbe ^iead; the wound healed, and the man returned to his duty.reajC Ve P^o.nths afterwards, having got drunk, he fell down in the streets of Mont- .Medico-ciiirurgical Review.[April 1 the man to have the bone removed.H declined, but begged to have more to eat, which I in turn refused.He had no bad symptoms, and the wound closed in, and had healed when I left him at Bordeaux about to embark for England.It was the recollection of these cases which induced me, after the battle of Waterloo, to recommend, in that of a soldier similarly wounded, that nothing should be done unless symptoms arose demanding the use of the trephine ; as none appeared and the wound healed, the man was sent home to Colchester, where he one day got drunk, and also fell down dead in the market-place.The ball was lodged deeply in the posterior lobe of the brain in a sort of cyst.I have never seen a person live with a foreign body lodged in the anterior lobe of the brain, although I have seen several recover with the loss of a portion of the brain at this part.My experience then leads me o believe, that an injury of ap- parently equal extent is more dangerous on the forehead than on the side or middle of the head, and much less so on the back part than on the side." 3.A fracture of the vertex is infinitely less serious than one of the basis.The latter obtains most in civil and ospital practice?theformer on the field of battle.Hence, perhaps, one reason for the difference of opinion between army surgeons and those attached to the metropolitan hospitals.Mr. Guthrie refers to the experiments of Flourens, Mayo, and others, on the destruction of parts of the cerebrum, &c. and to the researches of Dr. Marshall Hall on the excito-motory system of nerves.Applying the facts elicited by these gentlemen to the prognosis of injuries of the head, he concludes that,?"Great severity, and persistence of the symptoms lead to the belief that the part of the brain, or spinal cord on which they depend, is directly injured rather than indirectly affected, and that the re- sult is more likely to be fatal.Permanent insensibility and loss of motion may depend on cerebral mischief only.The loss of the mobility of the iris implies an affection of the tubercula quadrigemina.Convulsions, vomiting, a drawing up of the limb not affected by paralysis, stertor, a difficulty in swallowing, strabismus and relaxed sphincters, show derangement of the spinal functions ; whic is well marked when tickling the eyelashes causes no closing of the lid, the verge of the anus no contraction of the sphincter, the sole of the foot no motion of the toes."Mr. Guthrie passes to the consideration of Concussion.He comes to the conclusion that the exact condition or lesion of the brain is far from being very clear, whilst he agrees, as all rational thinkers must, with Sir B. Brodie, that " there may be changes and alterations of structure in the brain, which our senses are incapable of detecting."Speaking of the impossibilit of determining what amount of injury is necessary to give rise to fatal concussion, he relates a remarkable circum- stance:?"Two men were brought to the Westminster Hospital appa- rently dead; one had fallen from the dome at the top of Buckingham Palace on the back and head of the other, who was walking unconcernedly below, and who was killed on the spot, altho gh no bones were apparently broken.The man who had fallen from the dome?perhaps the greatest height from which any one has fallen without injury, was quite well ?n the third day, felt only a little stiff, and left the hospital to return to his work."We once saw a man brought into St.George's Hospital, who had fallen from the top of one of the houses in Belgrave Square, before the building was completed.The fall had been broken by the scaffolding, and he lit 1843]Mr. Guthrie on Injuries of the Head.295?n some loose rubbish on the ground.He was taken to the hospital for dead.Gradually he was prevailed on to open his eyes, move his limbs, sit up, get up, and walk to bed.There was nothing the matter with him.Mr. Guthrie adds :? <c I once saw a girl of ten years of age fall thirty feet from the parapet of a house on the ground, which was rather soft; I ran to her, thinking she must be killed, but she got up, and ran away roaring and rubbing her bottom, which deemed for several days the only part inconvenienced by the fall.I have read 111 one of the older authors, however, of a young Dutch girl, who, falling in this was so much shook by it and by the rebound, as to suffer afterwards lrom suppuration on the dura mater at the vertex, requiring the use of the tre- phine."io.Mr. Guthrie goes on to give a full account of the symptoms and pro- gress of concussion.We shall only allude to such points as strike us.He gives a caution against admi istering liquids to a patient in this state, before he is well able to swallow.Mr. Andrews mentioned to him Jhe case of a man who was taken to the London Hospital.After drinking "e had fallen down stairs, vomited, and died.Nothing could be found of any importance on examination, save some meat in the pharynx, a portion which had also slipped into the glottis during vomiting, and had suffo- cated him, Mr. Guthrie has seen a man killed by being made to vomit ^hen lying on his back \ and in all cases of insensibility the person should ?e raised when it is intended he should swallow, and a small quantity only, anything, should be given at one time.There can be no question that the act of swallowing is an excited act, and being induced by the contact of a substance with the fauces is thence- ?nvard involuntary.But we have only to observe an apoplectic or a paralytic Patient to be satisfied of th influence of the brain.Attention and voli- l0n are very requisite for the safety and precision of the process.Vomiting is, in general, an early symptom of returni g sensibility.But may wait on extensive lesion.Petit relates the case of a man who died tter continued vomiting for seven hours ; an enormous quantity of blood ^as found in the ventricles of the brain.We have all seen vomiting usher ln apoplectic paralysis or coma, and it is notoriously a symptom of many

sma'in! i ^ec*" ^ie was f?un(l on the corpus eallosum, where it had made a eacj *}ole or sac for itself.After the battle of Toulouse I had three cases, in direct]

.a Piece ?f the occipital bone was driven in by a ball, which, striking of y uP?n it, made a hole no larger than the end of the inger : the absence One ri?US syraPtoms in these cases insured exemption from operative treatment, hall CaS? Yas' however, peculiar : the part injured was so exactly the size of the whilst H 1 i ?rganic cerebral lesions.We remember a case of tumor of the cerebellum, ln Which incessant vomiting was the prominent feature.extract a rather long note on the conditions of the iris.

" Great stress has frequently been laid by writers on the mobility of the iris, as n indication of concussion, or of compression, or of irritation of the brain.I ^Ught in my Lectures, as early as the year 1818, that the motions of the iris ^ e.re influenced in three ways; one by the direct stimulus of light, the patient r ei.n? quite blind ; and two by sympathy or indirect influence; the first, with the wh ^ ^ie same eye when sound; the second with the iris of the other eye, ler the retina was healthy or otherwise.The facts were stated from the or Serv^on ?f these parts in man whilst in health and under disease; and little torn"?has been added to our knowledge on the subject by experimental ana- ey y* It has, on the contrary, tended to obscure it practically, although it may dis UaUy useful: for the surgeon would be led into error in the treatment of ''T^S ^le eye' w^? attended to it alone.

.he optic nerve is probably not a simple but a compound nerve, and possesses "icident and reflex fibres of Dr. Marshall Hall in addition to those for sen- X 2 [April I   sation; the former exerting an influe ce perhaps on the motions of the iris, which is more distinctly supp ied with nerves from the lenticular ganglion.When the optic nerve is divided within the cranial cavity, the iris, it is said by Mayo and by Flourens, loses its contractile power, although it may be again excited, and the pupil be made to contract by irritating the root of the optic erve still attached to the brain.A man may, however, be blind from a defect in the retina or in the optic nerve, and utterly incapable of distinguishing light from darkness ; yet the pupils will contract and dilate under the proper influence of light, proving that it is not on the optic nerve, as one of sensation, that these changes depend.

The division of the optic nerve within the head commits in all probability a greater and a different injury on the parts than that which takes place from dis- ease.

The part of the brain may not be sound in which perception lace, whilst that part may be healthy

o wh
ch other impressions are conveyed.Vision may be lost, yet the iris may be movable.The cerebrum m y be injured, yet the cerebro-spinal column, and particularly the corpora quadrigemina or upper part may be sound.An injury to the third nerve paralyses the iris.It is said that an injury to either of the corpora quadrigemina does the same.A certain kind of injury to the fifth nerve may deprive a person of sight, but it does not always at the same time affect the motions of the iris.

"None of the changes which take place in the appearance of the iris can then be considered as distinguishing signs of concussion or compression, or of irrita- tion of the b ain; they merely imply that a derangement of a particular part has taken place within the head, which may not be perceptible on examination after death, or which may subside and be removed without leaving any permanent defect." Dr. Auchinclose has related a case in the Glasgow Medical Journal, copied into the sixth volume of the Medical Gazette, in which, after an injury to the head, he found the left eye was blind, yet the iris acted freely, and the patient recovered.

" Mr. Hancock, when House Surgeon of the Westminster Hospital, examined the head of a woman, a patient of mine, who died three weeks after the receipt of a blow which was considered to have caused only a concussion of the brain-

The pupils contracted for several days before her death, separately and conjointly* although the levator muscle of the left eyelid was paralysed, and the eyelids ap- peared to be nearly clqsed.An abscess had formed in the base of the skull, implicating and destroying the third nerve of the left side at the point at which it leaves the crus cerebri, which led him to think that the mobility of the ins might continue after the motor oculi or third nerve was separated from the brain- The other muscles of the eye supplied by the third pair were also implicated, and the eye was fixed and the conjunctiva inflamed." 16.

After alluding to stertorous breathing as a symptom of compression.

Mr. Guthrie observes that another modification of breathing is e ually characteristic and dangerous?it is a peculiar whiff or puff from the corner of the mouth, as if the patient were smoking.This is not an uncomm011 feature in apoplexy, and is, in fact, a modification of stertor.

Mr. Guthrie also adverts to the slow and laboured pulse which usually waits on pressure or extravasation, but takes occasion to state that many of the largest extravasation he has seen, and many of the most diffused, have been accompanied throughout by a very quick pulse.Yet, wherever he has made pressure on the brain or dura mater during life, a diminution of the frequency of the pulse has been the consequence.

Whilst speaking of the effects of bloodletting in concussion he relate13 two or three cases illustrative of the bad consequence of pushing it too far-

^ 843]

Mr. Guthrie on Injuries of the Head.


29/

Perhaps one, communicated to him by Mr. Andrews, of the London Hos- pital, is as striking as any.

" A young gentleman struck his head against the ground by jumping out of a ehaise, which slightly stunned him, but did not prevent his walking home, nearly ^ mile.He was bled to thirty ounces, but gradually becoming more stupefied, he was bled again to thirty ounces more.This was followed by convulsions, and at| increase of the comatose symptoms, for which external stimuli were used with advantage.It was now thought necessary by another surgeon to open the tem- poral artery, but a small quantity of blood only was abstracted, when the patient died." 21.Mr. Guthrie offers the particulars of several cases illustrative of the effects of bleeding.H s opinions on the point are the following;?" There is then a time, when the stage of depression is slowly passing into that excitement, in which it may be doubtful what quantity of blood, if any, should   .fetaken away; but the loss of six, eight, or even of ten ounces can do no harm they do no good, and their loss may enable the surgeon to form a more accu- rate judgment of the state or degree of the complaint than he could otherwise ^ave done.When the period of excitement or of inflammation ha begun, and :"e patient, although ' disposed to coma, but when roused is still irrational and ^patient,' he is not to be left to await the effects of a blistering plaster or a dose ?f physic, as has been recommended in such cases, but ought to be bled sitting j'P in bed to whatever extent may be necessary to relieve he symptoms, or at ieast to cause a near approach to fainting, for nothing less can relieve such a Person effectively, and give him a fair chance for life.The bleeding must be Readily repeated as the symptoms recur until relief is obtained, or until it be- j^fles evident that the powers of the patient cannot resist the inroads of the lsease and of the efforts made for its cure.The quantity of blood lost in two r three days is sometimes enormous in powerful healthy men, amounting to 150, and even 200 ounces, with the happiest effect." 22.

. There can be no doubt that many a life has been saved by active bleed- There can also be no doubt that many a life has been destroyed by '

The juste milieu is not always easy to be hit, and certainly cannot eu be

fined.
ut it is something to put surgeons on their guard and 0 lrnpress them with the conviction that there are dangers on both sides, and that discrimination is necessary.

Mr. Guthrie relates several other cases, and then proceeds to observe, lat " in the less important cases of injury one bleeding will answer the ?Ur ?se, cupping and leeches may also be resorted to with advantage ; bu aU very severe ones general blood-letting is the only trustworthy source ?* belief.It should always be done with effect, the finger examining the opposite pulse and regulating the amount to be taken away.At an early Period of concussion the quantity should not be large : it should increase rth the urgency for its abstraction, and diminish with the frequency of the petition, being always, however, carefully regulated by the effect.The .auility of blood-letting to overcome the disease will be shown by the crease in frequency of the pulse, its diminution in power under slight 0lnpression, its greater softness, together with the persistence of the other symptoms.


0r

*n these cases that repeated small bleedings, to the amount of six th ounccs> ought to be resorted to, and when it is doubtful whether loss of blood can or cannot be borne; they may then be considered [April 1 not as curative but as explorative measures, although they may sometimes prove very effective."

In these cases, calomel given early and rapidly, particularly if combined with opium, may be " decisive."We apprehend that, in head cases, the general employment of opium, even in combination with mercury, is not free from objection.Not that we would proscribe opium, but we think that calomel alone, or in connexion with James's powd r, is, in many instances, preferable.Blisters, at a later period, shaving of the hair, cold lotions or ice to the scalp, are all, of course, recommended.But Mr.

Guthrie does not mention, what we have seen of great utility, the application of a blister to the scalp and dressing the surface with mercurial ointment.This measure is necessarily applicable to the later stage of inflammation of the brain or of its membranes, after depletion and the internal exhibition of mercury.

Mr. Guthrie refers to the insensibility produced by inebriation, and the possibility of its being mistaken for the effects of injury.But the odour of spirits is demonstrative of the fact, and the stomach-pump is the remedy-" There was a man in the neighbourhood of the Westminster Hospital formerly, who frequently got drunk and as generally fell down apparently insensible, and was brought to the hospital.The first time there was some doubt about the case, but never afterwards; and he became so fearful of the pump as to take care that he got drunk only when at a distance from his home."The difficulty however, in some cases, is this, to deter- mine when an intoxicated person has fallen, whether cerebral injury may not be combined with the intoxication." There is another kind of case of infinitely more importance; it is when mania supervenes on the injury, from the consequences of which it has often be n undistinguished.It occurs only, I suspect, when the sufferer has an hereditary predisposition for insanity, and rarely unless he has shown some previous symp- toms of such derangement.The first case I saw of the kind was in a soldier after the battle of Salamanca, who had suffered a slight injury of the head, and my suspicions as to the nature of the case induced me to examine the brain after death, when nothing could be found to account for it.The second o curred many years ago in the Old Westminster hospital: the man had fallen from a moderate height, and suffered from the ordinary symptoms of concussion through the first and second stages, when they assumed those attendant on mental de- rangement.He sat up, talked irrationally as well as incoherently, required some restraint to keep him in bed, owned to no complaint, would eat as well as drink anything that was offered to him; the pulse never ranged above 88, and all the ordinary functions were regular.He died at the end of three weeks apparently exhausted, and nothing peculiar could be perceived in the brain.This ma? might possibly have recovered under the use of opium, which I have since found of great utility in several cases ; the preparations I prefer are those of morphia which seem to cause less headache and less confinement of the bowels, although they sometimes give rise to nausea and sickness, when the dose is too large." 29- Our readers are aware that morphia has been much lauded in cases of mania, and does certainly in some instances prove serviceable.But cannot help thinking that more harm than good has been done by it, and that there is an extravagance in this direction, as well as on that o* depletion.

Mr. Guthrie touches on the more remote effects of concussion upon thc brain and its membranes.The patient may suffer little, or not at all, at the period of the accident, but subsequently suffer from pain in the head or other symptoms.He relates a case in which very large bleedings were practised for such symptoms and procured perfect relief.

The convalescence after injuries of the head requires extreme care.

Relapses are frequent, and undermine the health." In many instances," says Mr. G. " and particularly among poor people subject to privations and of irregular habits, in whom an injury of the head has not originally been of any apparent importance, such a state of irritation, combined with debility, is very difficult to manage, and requires a combination of local as "Well as of general means for its cure.A few leeches and blisters may be applied alternately over the part affected, with great advantage, and a mild nourishing diet with gentle alteratives and tonics will expedite the cure, specially when aided by perfect repose and a fresher atmosphere.In persons of a higher station, who rather suffer from casual irregularities, I have found an issue in the arm, which establishes a gentle but permanent drain, a most efficacious remedy; and I am in the habit of recommending rts adoption in all cases of affection of the head' among elderly persons, in 'Which any material or long-continued inconvenience has been suffered."

Mr. Guthrie passes to the subject of extravasation of blood within the cranium and compression, and seems to lean to the opinion that the brain compressible.But the knotty question is not much smoothed down, and we must admit that our author leaves it pretty much as he found it.

Our author gives a copious account of the symptoms of compression, -^he only point to which we shall allude is the relation between the side ?f the brain affected and the side of the body paralysed.After quoting ?pinions,Mr. Guthrie observes, that " Burdach found in 268 cases of lesion one side of the brain, that ten presented paralysis on both sides of the body, two hundred and fifty of one side, and of these, in fifteen the paia- vsis was on the same side as the injury.The convulsions were in twenty- ,e cases on the same side as the disease; in three cases on the opposite Side.In cases of lesion of one corpus striatum, there were in thirty-six instances paralysis of the opposite side, and six with convulsions of the same side, and in no instance convulsions of the opposite side.In twenty- eight cases of cerebral lesion of one side the muscles of the opposite side the face were paralysed, in ten cases those of the same side.Paralysis the eyelid was in six cases on the same side, in five on the opposite Slde.Paralysis of the muscles of the eyeball occurred in eight cases on the same side, in four on the opposite.Paralysis of the iris in five cases ?n the same side, and five on the opposite; the tongue being generally drawn towards the paralysed side of the face."Mr. G. alludes to several other opinions, but to mention them is sufficient to expose their hollow- ness.

We extract Mr. Guthrie's observations on convulsive movements of the 1Inbs, after injury of the head?a subject full of difficulty.After re- marking that they have been known from the earliest antiquity to occur, a d it has been also known that they generally affect the side opposite the Paralysed one.


^

When the paralysis is not complete, I have frequently seen that side affected y slight convulsive twitches, whilst the other suffer d from well-marked spasms;

[April 1 leading to the belief, th t whilst paralysis is an affection of only one half of the brain of the opposite side, or of half of the spinal marrow of the same side, con- vulsions are the effect of a more general irritation, capable however of being con- fined to a part; for partial convulsive motions do very frequently occur without any paralysis accompanying them on the opposite side, and I have not seen these convulsive actions occur, as far I can recollect, where both sides have been paralytic from injury of the head, although spasms and twitches are symptoms of daily occurrence in paraplegia from disease of the spine.I have met with se- veral cases in which the convulsions have ceased and the patients recovered after the removal of a portion of bone which was irritating the brain ; but convulsions have generally been the forerunners of death when the seat of injury was un- known and this assistance could not be given.When they occur in cases appa- rently of pure concussion, accompanied by inflammation of the brain or its membranes, and the patient recovers after many days of the strictest antiphlogistic treatment, it is possible that the brain may have been lacerated and the cure have been effected by adhesion.Convulsions, it must be remarked, are among the most common symptoms of inflammation of the membranes of the brain, without any such lesion of its substance, although they are frequently wanting.They may be expected to take place a out and after the fifth day in injuries of the head, when inflammation of the brain or its membranes is about to extend to or become continuous with the neighbouring parts, and may be more or less severe, varying from a state of partial trembling of a limb to that of general agitation and rest- lessness of the body generally; from a slight irregular movement of the eyelids, or muscles of the face, to the more marked spasmodic startings of the whole of one side, grinding of the teeth, and contraction of the limbs.Sir B. Brodie has well shown in his memoir, that they may exist at a late period independently of inflammation, ' being aggravated by any additional abstraction of blood, and sub- siding on the patient being allowed to take some more substantial nourishment than that which had been allowed him previously.'They would seem in these cases to be dependent on the same or similar causes to those which gave rise to them after the loss of too great a quantity of blood in the first instance, and to be relieved or remove in a similar manner.It is far different with those convulsive movements which, at a late period, became nearly permanent or rigid spasms, resembling tetanus, in which the body is drawn in different directions forwards, backwards, or to one side.They are for the most part the forerunners of death; fortunately they are seldom present except in very hot weather,* and are not even then of frequent occurrence.Examination after death in such cases has shown nothing discoverable beyond inflammation of the pia mater, and an effusion of fluid, generally purulent, on the surface of the brain or in its ventricles, or between the pia mater and tunica arachnoides." 50.

Amongst other cases bearing on the point, Mr. Guthrie relates an interesting one which Mr. Keate took him to see in St. George's Hospital.It seemed to be an instance of injury of the head and paralysis on the same side.The paralysis although positive, was not so complete as to render the patient quite incapable of moving the arm and leg, which were frequently convulsed, although the convulsions which were observable in both were more marked on the opposite or left side.But on dissection the apparent anomaly was cleared up.For, the most seri- tending to the petrous portion of the latter, and beyond it, which, with the ather large extravasation of blood under and in the course of.the fracture, appeared to be sufficient not only to destroy life, but to have caused paralysis of the left side, which it did not do.Another extravasa- tion, rather less in quantity, had however taken place under the upper and anterior portion of the left parietal bone, which enabled him fully to account for the paralysis which took place on the right side, and which nothing but a post-mortem examination could have made known.

Mr. Guthrie, like all surgeons of experience n the present day, is no advocate of the trephine.In cases of fissure of the cranium, or of simple fracture, if no symptoms of compression exist, it is improper to resort to it.

If symptoms come on, it will be time enough to act upon them.

Mr. Guthrie observes :?

" After the receipt of a severe blow or a gun-shot fracture of the head, which has not even stunned the person at the moment, he may walk to the surgeon, and be dressed, and converse with his fellows as if nothing had happened; yet a short time he becomes heavy, stupid, drowsy, unwilling to move, with a slow pulse an a pallid countenance.Inflammation has not yet had time to set m, and extravasation has not always taken place.If the loss of a moderate quantity of blood should relieve such a person, it shows that congestion had pccurred, perhaps on the surface of the brain under the injured spot; recover- ing from which by the unassisted efforts of nature, he would still be liable to inflammation.I have repeatedly seen a sharp bleeding from an incision made to allow a complet examination of the part in such a case, cause the restor- ation of the patient to his natural state.A return of untoward symptoms during the progress of the case does not always indicate essential mischief, and will be Removed, if of a temporary nature, by a further moderate bleeding, by purga- tives, and by greater restriction in diet, through irregularities in which, these secondary attacks most usually occur.If the loss of blood should not relieve the symptoms, the case is probably complicated by an extravasatio having taken place between the dura mater and the bone, or even in, or on the surface ?f the brain." 58.

Mr. Guthrie adverts to injury of the parietal bone occasioning rupture pf the middle meningeal artery, and effusion of its contents.If the case *s recognised, it is, of course, proper to trephine.But Mr. Guthrie ob- serves :?" Experience has demonstrated, that persons have recovered after large coagula have been removed; but in all these cases the brain had not lost its resiliency, and had been seen to regain its natural level ?n the removal of the depressing cause.I have several times seen the depressed brain gradually recover its natural position, and the person open his eye3, and recognise and speak to those about him; but I never saw the symptoms mitigated, or the persons in any way relieved, when the hrain remained depressed after the blood had been removed."He relates some cases illustrative of this position.

. Serious, and commonly fatal, as fracture of the base of the cranium is, *t is not universally so.From several cases, intended to illustrate this, we select one, communicated to our author by Mr. Keate.

Case.?" A young gentleman, eleven years old, fell down a flight of kitchen- s airs, on a stone pavement on his face, in September 1839; his nose bled con- erably, and appeared to be flattened and a little out of shape: he complained ?nly of the pain of his nose, which in a few days quite left him.Three weeks- [April 1 afterwards an abscess formed behind the left ear of the size of a small hen's egg, which was opened and healed.He then went into Devonshire, and re- mained some months apparently in perfect health, when, without any cause which his friends could assign, he every night suffered from retching without actually vomiting, which gradually subsided, and he afterwards passed a good night.In December 1840 he died after a short illness, his death being preceded by all the symptoms of hydrocephalus, and Mr. Norton furnished Mr. Keate with the following report of the post-mortem examination.The width of the head from ear to ear was greater than usual in a child of his age; the pericranium was easily separated from the left parietal bone, which appeared disco- loured ; the dura mater appeared more vascular than usual; the sinuses were full of blood; there was considerable effusion between the dura mater and arachnoid membrane, and some coagulated lymph around the tract of the optic nerves, which were soft, and readily torn across; a quantity of serous fluid escaped from the ventricles, of which six ounces were preserved.On removing the brain a small abscess was discovered upon the sella turcica, and the bone in front was very rough.A fracture or fissure was also perceived running across from the temporal and between the sphenoid and ethmoid bones, and which no doubt was occasioned by the fall he had received fifteen months before."70.

Our author alludes to a very serious symptom, after injuries of the head ??the discharge of a watery fluid from the ear.This, pro ably, comes from the sac of the arachnoid membrane, and is indicative of great danger.In these cases, the principal fracture is usually in the direction of the petrous portion of the temporal bone, and towards the body of the sphenoid.Although the extravasation of blood, may take place from a rupture of the lateral sinus, it is as frequently found under the middle, or one of the other lobes of the brain, accompanied by laceration of its substance.Mr. G. has seen the fracture pass across the carotid canal, and the extravasa- tion caused by the rupture of the artery.

Fracture and depression of the inner table of the skull, without fracture of the outer, ne t occupies our author, and he quotes many authors and their cases.But per aps none are so satisfactory as De la Motte, who supposed that, when the inner table was broken without the outer one, the patient might be aware of the fact, by the peculiarity of sound which fol- lowed the blow, resembling that given out by a broken pot when violently struck, and he relates a case in illustration of this idea.It must be owned that the diagnostic sign is likely to prove very valuable.

Mr. Guthrie, however, very justly, as it seems to us, discountenances the notion that depression of the inner table, without fracture of the ex- ternal one, is a common accident, or one warranting interference.He remarks :?

" I therefore think it safe and reasonable to come to the conclusion, that al- though these things have happened, they will rarely occur again.I have never, in the great number of broken heads I have had under my care on many differ- ent, and grand occasions, actually known the inner table to be separated from the outer, without positive marks of an injury having been inflicted on the bone or pericranium, however slight that injury may have been; and although it is not possible to doubt the fact of fracture of the inner table having occurred, it is very desirable in a practical point of view not to bear it in mind; for if a surgeon should be prepossessed with the idea that the inner table might be so readily frac- tured, and separated from the diploe placed between it, and the outer table , and     1843] Mr. Guthrie on Injuries of the Head.

thus cause irritation or pressure on the brain, few persons who had received a knock on the head, followed by any serious symptoms, without fracture or de- pression, would escape the trephine, and the worst practice would be again esta- blished.An operation should never then be performed under the expectation that such an accident may have happened, unless it is apparently required by the urgency of the sympt ms indicating compression or irritation of the brain, which cannot be relieved by other means." 79.

[April 1 through which it fell, making the estimated force with which it struck the head equal to sixteen pounds.The immediate effect of the blow was insensibility, followed by acute fixed pain in the head, which has ever since continued to mark the seat of injury.A week after the receipt of the blow she began to lose the power of moving of the right arm, there being however no loss of sensation or any disturbance of the cerebral functions.

" During the following twelve months her symptoms remained unchanged, and this period was spent in Guy's, St. Thomas's, Westminster, and St. George's Hospitals; but having derived no relief whilst in any of these institutions, she became an out-patient under the care of Dr. Roe.

" After the lapse of a few weeks the paralysis of the arm suddenly increased, sensation still being unaffected, and she experienced no further change in her condition until after eleven months, when she was again admitted into the hos- pital, her symptoms then being the following:?the arm and leg of the right ide quite paralytic, the former, which had previously been flaccid, having now become remarkably rigid, and its temperature being below that of the opposite side; vision, particularly of the left eye, imperfect, the pupils however acting naturally; hearing on that side also affected; memory bad; respiration fre- quently slow and almost stertorous; the countenance assumed a dull heavy ex- pression, and she manifested an unusual tendency to sleep.All the ordinary remedies havin failed to relieve these symptoms, Mr. Guthrie was requested to see her, and he operation of trephining was eventually agreed upon.

" April 1st, 1841.?Mr.Guthrie this day removed a disc of bone from the exact point in the parietal region to which she referred the pain.The portion of bone presented no evidence of disease ; its thickness varied from two and a half to four lines, the latter measurement corresponding to the part most distant from the sagittal suture: the vessels of the diploe bled freely, the dura mater was quite healthy, and without any very evident motion.


"

On visiting her an hour after the operation, she raised the previously para- lytic arm several inches from the bed, and was able to bend, and extend the fin- gers.The pain in the head was considerably less, and her countenance, befor dull and heavy, was now remarkably animated.Sensation had returned in the arm, and partially in the leg.Her pulse was calm, and skin cool.

" Ten hours after the operation she was attacked with rigors, followed by py- rexia and all the symptoms of commencing inflammation of the brain.By the immediate abstraction of blood, which was three times repeated during the suc- ceeding twelve hours whenever the pain in the head or the force of the circula- tion increased, every bad symptom was removed.In the course of three days the paralysis had completely disappeared, sight and hearing again became perfect, and after passing through a speedy convalescence, she quitted the hospital completely recovered." 85.

Certainly, the preceding is a singular case."We are told that the girl has since had some relapses of pain and uneasiness in the head, and that she is of a very hysterical temperament.Could the symptoms have been of this character ?We know how many forms they assume, and how they sometimes, by a sort of caprice, yield to operations or to remedies which are generally unadvisable.The absence, in this instance, of any perceptible lesion, the sudden recovery without'any assignable reason, and the temperament of the girl, render this not altogether improbable.At the same time there is a per contra, which throws a great degree of ob- scurity upori the case.

Mr. Guthrie directs attention to a peculiar fracture of the inner table.

It occurs from the blow of a sword, hatchet, or other clean cutting instru- ment, which goes through scalp and skull into the brain.It is usually supposed that in this instance there is no fracture, but an incised wound of the bone.When the outer table only is divided, it should be so treated; and so it should be when the diploe is involved.But " when the sword o axe has penetrated as far as, or through the inner table, the case is of a much more serious nature ; for this part will be broken almost always to a greater extent than the outer table ; and will be separated from it, and driven into the membranes, if not into the substance of the brain itself; the surface of the bone showing merely a separation of the edges o the cut made into it.These cases should all be examined care- fully.The length of the wound on the top, or side, or any part of the head which is curved and not flat, will readily show to what depth the sword or axe has penetrated.A blunt or flat-ended probe should in such cases be carefully passed into the wound, and being gently pressed against one of the cut edges of the bone, its thickness may be measured, and the presence or absence of the inner table may thus be ascertained.If it should be separated from the diploe, the continued but careful insertion of the probe will detect it deeper in the wound ; a further careful investi- gation will show the extent in length of this separation, although not in "width ; and will in all probability satisfy the surgeon that those portions of bone which have thus been broken and driven in, are sticking in or irritating the brain.In many such cases there has not been more than a momentary stunning felt by the patient; he says he is free from symp- toms, that he is not much hurt, and is satisfied he shall be well in a few days."Mr. Guthrie relates some cases in point.Perhaps the first is as much so as any.

Case.?" An officer was struck on the head in Halifax, Nova Scotia, by a drunken workman with a tomahawk, or small Indian hatchet, which made a perpendicular cut into his left parietal bone, and knocked him down.As he soon recovered from the blow and suffered nothing but the ordinary symptoms of a common wound of the head with fracture, it was considered to be a favourable case, and was treated simply, although with sufficient precaution.He sat up, and shaved himself until the fourteenth day, when he observed .that the corner ?f his mouth on the opposite side to that on which he had been wounded was fixed, and the other drawn aside; and that he had not the free use of the right arm so as to enable him to shave.He was bled largely, but the symptoms in- creased until he lost the use of the right side, became comatose and died.On examination, the inner table was found broken, separated from the diploe, and driven through the membranes into the brain, which was at that part soft, yellow, and in a state of suppuration." 87-  The application of the trephine is, of course, the proper practice.The following is an instance of it.

Case.?A soldier was wounded by a sword on the top of the head.The bone was apparently only cut through, but the inner table was depressed, [md felt ragged under the' probe.On the fourth day, the symptoms of inflammation increasing, and not being relieved by bleeding, Mr. G. re- moved a central portion of the cut bone by one large crown of the trephine, and took away several small pieces which were sticking into the dura mater, after which all the symptoms gradually subsided.

Mr. Guthrie quotes a case and an opinion of Sir Philip Crampton's.

[April 1

The case we may omit?the opinion is to the effect that where, in fractures of the kind we have been discussing, a fragment of inner table is driven into the brain, it is better not to trephine at first, for, argues Sir Philip, " The operation, in the first instance, would have been an additional violence to parts already severely irritated, and consequently an additional source of in- flammation.It would besides have removed all support from the wounded brain, a great part of which would (it is probable) have escaped through the opened dura mater.If the patient escaped these first dangers, then came the danger of hernia, or rather fungus cerebri?one of the most frequent and dangerous con- sequences of wounds of the dura mater."90.

But hear Mr. Guthrie on the other side :?

" It appears to me that too much stress is laid upon a difference which is sup- posed to exist in the danger of trephining a man on the first or on the seventh day after an accident, and that an error may be committed in believing that the trephine is a more dangerous instrument on the first day than on the seventh.The question here is not whether the man is to be trephined or not ?but which will be the best and safest day or time to do the operation ?I do not hesi- tate to say the first day.I believe the violence to be greater when done on parts already in a state of inflammation than when they are sound.I am quite satis- fied, that when the inner table is sticking through the membranes and into the brain itself, the individual will in most cases ultimately die miserably of the ac- cident if not relieved by art; and that it is less safe to let him designedly run the certain risk of cerebral irritation, which when once excited is often indomit- able, than to remove the cause, and so endeavour to prevent the evil.If the cerebral irritation only manifested its effects on the surface of the dura mater by causing suppuration there, I might yield my opinion, but as I know that it often gives rise under these circumstances to the formation of matter on the surface of the brain, and under its membranes, where it is generally deadly, I cannot assent to that which may be called ' la chirurgie expectante.' Lastly, I do not think that there is more danger of a hernia cerebr when the operation is done early than when it is done at a later period ; on the contrary, I think the patient has a much better chance of escape from hernia cerebri, and from all other evil, when the local and the general treatment are alike immediately decided, and efficient."92.

There is much to be said then on both sides.Nay, Sir P. Crampton's opinion is reinforced by Mr. Colles, who, in reference to another case, re- marks?"In very small depressed fractures (such as may deserve the name of punctures of the bone), where a depressed bit of bone is sunk into the brain, it will perhaps be prudent to postpone the operation for a few days.

For if the operation be performed immediatel after the receipt of the injury, and if we attempt to seize the depressed fragment, the first touch of the forceps sinks it more deeply into the brain; portions of the brain, from the softness of its texture, rise up and conceal the bone both from our sight and touch, whereas, if we defer the operation for a few days, we give time for the adhesive inflammation to take place; this circumscribes the depressed piece, hardens this spot of the brain, and thus enables us more easily and certainly to lay hold of the fragment of bone."

For our own parts we feel inclined to agree with Mr. Guthrie.If symptoms are likely to occur, and if the trephine will probably be neces- sary, it seems more consistent with reason and analogy to use it on unin- flamed than on inflamed parts, as a preventive measure than as a curative 1843]

Mr. Guthrie on Injuries of the Head.30/ one.

If, indeed, it could be argued that, in a large proportion of cas^s, symptoms are not likely to ensue, the case would then be different.Mr.

Guthrie reasons both ingeniously and forcibly upon the matter : " It is necesssary," he 6ays, " to recollect that the brain appears to be insensible, or nearly so, when first exposed; and it has rarely occurred to me to see a serious convulsion, or anything beyond vomiting take place on the removal of a piece of bone from the brain; nor do I suspect any difficulty will be found in removing such small fragments as can be seen, with a pair of forceps duly adapted for the purpose.It is impossible to say at what period of time the brain becomes irritable, and no longer admits of being touched without convulsive Movements ensuing; but whenever this state of irritation has commenced, and "s existence is proclaimed by the excitement which takes place on touching the fragment of bone, the surgeon should at once desist from all attempts to remove the foreign body.The brain under ordinary circumstances is, I conceive, much niore likely to recover from an injury, all foreign or irritating matters being re- moved, than when also suffering from their presence.Should I be mistaken on this point, the opinion generally entertained of the propriety of removing extra- neous bodies from wounds in general, must I imagine be erroneous.It is very inconvenient to r move a granule of iron which has been implanted in the cornea ^vhen the eye is irritable, and particularly when the surgeon has not a sharppointed instrument to lift it out with; it will doubtless be more easily removed ^vhen suppuration has taken place, but the cornea will be in a much worse state.There is in fact no comparison between the two modes of proceeding ; and I suspect it will be found to be much the same with the brain as with the c?rnea.


"

The establishment of the principles which ought to regulate the practice of surgery in cases of fracture and depression of the inner table of the skull is of the greatest importance, and it is on this account that I have quoted so many authorities on the subject.The principle being laid down that it is right and proper to examine all such wounds with a blunt flat probe, in order to ascertain " Possible whether the inner table is depressed and broken; the question neces- sarily arises, what is to be done when such depression and breaking down of the Jnner table is ascertained to have taken place ?There can be no hesitati n in answering; that in all such cases the trephine should be applied, although no symptoms should exist, with the view of anticipating them.The old doctrine, it may he said, in regard to fractures generally, is revived in these cases, but on a. principle with which our predecessors were not sufficiently acquainted.A patient very often survives a mere depression of the skull; he may, and occasion- ally does survive, a greater depression of the inner than of the outer table; b t 1 do not believe that he ever does survive and remain in tolerable health, after a Repression with fracture of the inner table, when portions of it have been driven |nto the dura mater.If cases could be advanced of complete recovery after such iiijuries, I should not consider them as superseding the practice recommended, Unless they were so numerous as to establish the fact, that wounds of the dura "later and brain, by pieces of bone, are not extremely dangerous.I have refer- j"ed purposely to many cases in which a cure was effected after a lapse of time, fy the bone being removed; but they rather support than invalidate the principle 1 have inculcated.There are great objections I admit to the trephine being ap- plied in ordinary cases of fracture, which are not attended by symptoms of further mischief; but the nature of the cases which I have particularly referred ?> having been ascertained, I maintain that the practice should be prompt and ecisive in every instance in which the surgeon is satisfied that there is not inerely a slight depression or separation of the inner table, but that several points ?.itare driven into the dura mater.If one trephine will suffice, the central Point being applied close to the edge of the middle of the wound in the bone, it [April 1 should be applied there; but if the cut be longer, and the spicula of bone extend upwards and downwards in its length, a small trephine should be applied as near each end as may be judged advisable, and one edge of the cut bone should be removed by the straight saw, of which Pare and Scultetus made such use in ancient times, and which Mr. H y of Leeds revived in modern surgery; or the small straight saw may be used alone, if the object of removing a portion can be attained without the trephine.By these means sufficient room will be ob- tained to remove the broken portions of bone which are irritating the dura mater, and brain."95.

.When the fracture of the cranium is from a sharp or weighty instrument impelled in a horizontal direction, the derangement of the inner table just noticed may not occur.The nature of the injury in such cases can be ore readily perceived, and the broken portions of bone removed.Hey's saw may be necessary, and the wound should be simply treated.

" When," says Mr. G. " a portion of bone is as it were sliced off with the scalp, and adheres to it firmly, the scalp and bone should be re-applied ; and the cure will often be effected without difficulty.When the portion of bone cut off, and hanging to the scalp which is turned down, has but little adherence, it had better be removed."95.

Several cases are related.But the following particulars are, perhaps, the most interesting." In the museum of the Royal College of Surgeons there are ten skulls which have suffered from very severe slicing cuts.They appear to have been collected from the burial-place of some establishment for invalid soldiers in Germany.The portions of bone thus sliced, and they are large pieces, were once detached, and afterwards reunited a little out of their proper places, so that the points of union and of separation can be distinctly seen.These fissures are all in a cer- tain state of progress towards being filled up by bone, and the patients must have lived some months, if not years, after the receipt of their respective injuries ; for bone is deposited apparently with difficulty, and most carefully in all such cases, so as not to irritate the membranes of the brain.The opening in the first instance is filled u by granulations, over which a thin skin is formed, this afterwards be- came firmer and harder, being in some cases, where the trephine has b en used, a thin but strong membranous expansion extending from one edge of bone to the other.In others it is thicker and more solid, and in a few instances osseous matter is deposited in its circumference so as in part to fill up the opening; the edges of the bony circle made by the trephine becoming gradually thinner as they appear to grow inwards.It is rare that an exfoliation does not take place from the edges of the cut bone, or from the circle made by the trephine.It has been occasionally observed after death, that the circular cut edge of the bone does not become thin in the manner described, but that a sort of ridge forms around and within it, which was thought to be the cause of death in some per- sons who died suddenly, and in whom no other derangement of structure could be perceived." 97.Mr. Guthrie is an advocate, of course, of union by the first intention in scalp-wounds, unless the integument has been excessively bruised.Speaking of erysipelas of the scalp, he directs attention to diffuse inflammation beneath the occipito-frontalis, and to the necessity for prompt and free incisions.All surgeons are agreed upon this head.We are not aware that the following practice is so universal.


"

Erysipelatous inflammation is more apt to follow punctured wounds in per*

'843]

Mr. Guthrie on Injuries of the Head.309 sons who live, or have lived irregularly; and the moment the parts around the cut or puncture have become puffy, the surface of the wound changing from a red to a yellowish colour, with a thin discharge instead of good pus, an incision should be made through them, and repeated in different places as often as may be f und necessary.It relieves the tension, and prevents the quickened pulse, the irritative fever, the delirium which would follow, and which neither bleeding, purging, nor the other constitutional remedies which the state of ever may ]ndicate, will remove.If it should be neglected, suppuration and sloughing will extend under the tendon of the occipito-frontalis, or the fascia of the temporal Muscle, as the case may be, and the greatest danger will be incurred.Mr. Pott, and many of the older surgeons, were, it is but just to say, aware of the value ?f incisions in such cases; and Dessault derived the greatest advantage from ernetics and purgatives, the use of which is deserving of the greatest atten- tion."102.

Mr. Guthrie dwells on the great distinction that obtains between de- pression of the cranium in children and in adults.In the former, the inner table does not break so readily, the brain bears pressure better, and the tavel of the bone is gradually restored.He believes that, for the last twenty years, the greater number of successful cases of recovery from depression or fracture of the skull, that were not trephined, were in young Persons.The following case is a marked one.

Case.?" Twenty years ago a small child fell over the banisters of the second floor in a public-house at the top of the Ilaymarket.I saw it as soon as possible afterwards, lying on the bed, motionless, senseless, breathless, with a hollow in t"e parietal bone that would have held half of a small orange, and I thought it dead.In a short time it gave a gasp, another followed at an interval so long to excite surprise, and a third shortly afterwards led to some hope.The potions of the heart and the pulse, which were only now to be felt, being equally ^regular and defective.It gradually recovered, and the next day breathed regu- arty> could speak, and answer shortly, although apparently otherwise stupid and Restless.Pulse 90, and regul r.Cold lotions were applied to the head.The oss of a little blood by leeches with some smart purgatives gradually removed ,j|e unfavourable symptoms, and the child began to walk about, with a hollow in le side of the head which exceeded anything I had seen before, and it was several veeks before the skull regained its level.The same thing then takes place in the Ending of the flat bones of the skull in young children, which is so often ob- served in the long ones at the same period of life."* 103., Our author now approaches a knotty question?theessential difference between a simple and compound fracture of the cranium.Our readers are aware that Sir Astley Couper insisted much on this distinction, and advised that, in compound fracture of the cranium with depression, the bontf Should be raised by the trephine, or otherwise, whether there were symp- ?ms of pressure or not.

Mr. Guthrie's ideas upon this subject diffei.

||0t only from those of Sir Astley Cooper, but from those of a large nura- er of surgeons of the present day.l ' Avellan says that a girl of fourteen had a depression of the right parietal j ?e .rom a blow, which gave rise to mental derangement, amounting almost to J?r riUty' ^or three months; at the end of which time th depressed bone adually resumed its level, and the girl completely recovered.In Quesnay, ernoires de l'Academie de Chirurgie de Paris, tome i."

No. LXXVI.


Y [April I

" The difference between a simple and a compound fracture of the leg is often considerable, it is more often dependent on egree: and when the fracture is nearly transverse, and the skin cleanly divided, the difference between it, and a simple fracture of the same part, is little more than one of time.I suspect this to be the case with an injury of the head, and my experience induces me to be- lieve that the difference between the two states in fractures of the skull has been much exaggerated; so much so, that I place no reliance on the supposition that there is more real danger in a case of fracture with depression in which the scalp has been divided, than when it has been only bruised, and not divided ; and I ap- prehend that in all cases in which a fracture with marked depression is known to have occurred in an adult, it is the best practice to divide the scalp, and ascer- tain the nature and extent of the depression.

" If the result of a great number of comparative trials should prove in favour of never, under any circumstances, raising a depressed portion of bone in an adult, but of leaving it to the efforts of nature, an incision in order to ascertain the state of parts below ought not to be made; but as such result is not likely to be ob- tained, according to my observation and experience, the practice recommended appears to be the best."104.

We apprehend, that most surgeons are now in favour of not cutting down on depressed bone, unaccompanied with wound, if there be no symp- toms.

If there are symptoms, all surgeons, we suppose, ivould cut down.

Mr. Guthrie's rule, always to cut down in an adult do s appear to us too absolute, and calculated to lead to abuse of the trephine.Such, at least, is our impression.Whether the rule of Sir Astley Cooper is not too ab- solute also, we will not take upon us to determine.We are rather inclined to think that it is ; and in a slight case of compound fracture of the cranium, with depression but without symptoms, we fancy we should pause before we used the knife.

But to return to Mr. Guthrie, and his opinions with regard to the trephine?

" The cranium," he proceeds, " together with the fracture and depression, being exposed, the question whether the trephine should be applied or not, is now to be determined.If the operation by the trephine, or that of sawing a piece of bone out of the head, was not in itself dangerous, there could be no hesitation about its use; but it is a dangerous operation, especially in crowded hospitals, and ought not to be resorted to when it can be avoided.I am of opinion, that if any ten healthy persons were trephined in an hospital, one would in all probability die froifl the effects of the operation; and that three or four more might have a narrow escape from the inflammation of the brain and its membranes, or the other con- sequences which would probably ensue.It is not the admission of air, which has been even lately supposed to do mischief, that is to be dreaded in these cases, but the same kind of irritation which often follows the abstraction of 3 piece of bone under other and more ordinary circumstances at a later period of time." 105.From several illustrative cases, we select what seem to us most characte istic.The following shows the time that a ball may lodge within the cranium with trifling symptoms, and their ultimately severe or fatal character.

Case.?" Thomas O'Brien, 28th regiment, aged twenty-three, was wounded by a musket-ball on the 16th of June at Quatre-bras; the bullet penetrated the occipital bone below and to the right of the junction of the lambd idal and 1843]

Mr. Guthrie on Injuries of the Head.sagittal sutures.On his arrival at Colchester, the wound was healthy in appearance and healing rapidly.It appeared from his own account that for some hours after the injury he was totally deprived of sight; since that time he has been constantly more or less affected with headaches, for which he has been prescribed occasional cathartics and low diet.He has been also affected with Pain and weakness in both eyes, but more particularly in the right.While at jprussels and during his progress to Ostend he lived very irregularly, and was frequently intoxicated; the external wound was entirely healed on the 20th of ^uly, and no sus

cion e
isted that the ball was lodged in the brain.On the 25th matter was perceived under the scalp, and was yesterday evacuated.To- ^ay> the 27th, he c mplains of increase of headache; pulse small and quick.? S ad 3yj.Haust.cathart.statim.28th.In the course of this day his ^'oiptoms have become very urgent; he is restless with a very quick pulse; an Extensive crucial incision was made in the site of the original wound, and now ?|" the first time it was discovered that the ball had penetrated the brain; seve- ral loose pieces of bone were extracted; a considerable quantity of arterial blood suffered to flow from the small vessels divided in the incision.His bowels ad been well opened by the cathartic.The most vigorous treatment was con- ^ued, but the symptoms notwithstanding increased, and he died on the morning ofcthe 29th of July. .


'

The ball was found lodged near two inches deep in the substance of the right posterior lobe of the brain; a considerable quantity of pus surrounded it; s?nie inflammation of the brain and its membranes was observed, but it was ^Uch less than might have been expected." 107.   the next case, the ball did not lodge nor irritate the brain, and the re<mlt was more fortunate. .Case.?A.Clutterbuck, 61st regiment, aged twenty-five, was wounded the back of the head by a musket-ball at the battle of Toulouse, on e 10th of April, 1814.He felt little inconvenience from the wound i e first two days.On the 14th he complained of severe pain in the ead, giddiness, and dimness of sight; the face was flushed, pulse hard fid frequent.Twenty ounces of blood were taken from the arm, and e "Wound enlarged to expose the cranium.The upper part of the os ??cipitis was found fractured by the ball, and a circular portion of it, ?ut the size of a shilling, was depressed and fractured.15th.Pain in head much abated ; no giddiness, dimness of sight, or any unfavour- able symptom; pulse still hard.V. S. ad 5XX.To be well purged.

He was bled again this day to the extent of twelve ounces, as a atter of precaution.23rd.Continues free from any bad symptom.

. ny 8th.The wound is now much contracted.He has been out of bed k?r some time past, and feels no inconvenience.A small portion of the ?ne still feels bare to the probe but the greater portion of the depressed j\lece is covered with healthy granulations.No exfoliation has taken anH?e' ?

^4th.The wound is nearly healed ; he is in good health sPirits, and without inconvenience.Discharged to Bordeaux.

. e introduce a third case of a different complexion, as it bears upon a ?"""t of treatment.

16th?Sf' " William Rogers, aged 19, of the 32nd regiment, was wounded on the fietal ?K ^Une ^ a musket-ball, which entered at the inferior angle of the left pa- bone ; it knocked him down, and for a few minutes 'rendered him sense- Y y 2

[April 1 less.On recovering liis mental powers, which he soon did, he found that he was unable to speak, not so much (as he says himself) from the want of power to form words, as from the incapacity of giving them sound.He as conscious of everything passing around him, and reasoned correctly: he retired out of the reach of shot, and then lay down for the night.On the following morning, finding the picquets retreating, he fell back himself on Brussels, where he was examined and dressed.On the morning of the 18th he reached Antwerp on horseback, very giddy, and ove whelmed with fatigue, fasting and watching; he was admitted into the Minime General Hospital, and put to bed, when he soon fell into a sound sleep, which ith some tea refreshed him much.

" June 19th.On examining the wound, the ball was found to have passed ob- liquely upward and backward at least two inches, and could be distinctly felt with a probe.It gave more the idea of having raised the outer table than that of having depressed the inner; both tables must however have been displaced.

The defect in speech was in some measure restored, and this with giddiness were t e only symptoms of compression.A poultice was placed over the wound, a sharp purgative iven, and spoon diet ordered.

" 20tli.The pain and giddiness having increased, with annoyance from noise and exposure to light, twenty-six ounces of blood were taken from the arm.The following day the purgative was repeated, and the patient was much relieved : a faltering in the speech continued for many days.

' Everything went on well, the wound was nearly healed, and he was considered almost fit to be discharged, when, on the lGth of July, the wound began to open; on the 18th it was dilated and a portion of the cranium removed by the forcep , which was soon followed by symptoms of inflammation of the brain, and twe

y oun
e of blood were taken immediately from the arm; purgatives and diaphoretics were ordered, and the strictest abstinence enjoined.23rd.Venesection was repeated, as well as the other means usually adopted to reduce high action.24tli.Completely relieved.Saline mixture continued; a little meat soup allowed.26th.Another portion of the cranium removed, the dura mater being fully exposed; the general health in the best state.

" August 3rd.Doing remarkably well; the wound healthy; the pulsation of the brain evident; the power of speech perfectly restored.The ball yet remains in according to the opinion of the patient (who is a fine intelligent lad), and he thinks has gradually descended towards the petrous portion of the left temporal bone.Sent to England at the end of the month well." 106.

Mr. Guthrie observes, upon this case, that the bone and ball ought to have been removed in the first instance.The subsequent operation perilled his life, and as he was discharged with the ball lodged (though, by-the-bye, this does not seem to us very likely, the dura mater being uninjured, and no symptoms existing), it is probable that he did not long survive.

Mr. Guthrie relates a case for the purpose of showing, to /what extent depletion may be advantageously carried.Case?Lawrence Moore, set.27, was knocked down oji the flight of,the 6tli of April, 1816, by a blow of a stone, which fractured' the upper, and, left edge of the frontal bone, the depression being about an inch and a half square.V. S. ad 3xxv.Took out the detached pieces of bone and dressed the wound simply; he lost about twenty ounces of blood during the operation.He had a pretty good night, but, on the 7th, pulse small and very hard; head feels to himself full, and gives the sensation as if ^ were bound with an iron hoop (his own words); eyes very suffused.V.


1843]

Mr. Guthrie un Injuries of the Head.313 ad 3I.with relief.At 8 r.M. the pulse having risen, V. S. ad ^xxv.with benefit.Elect, scammon.3ij.

Bth. Awoke better, but at 9 a.m. the pulse had risen to 130, hard and small; has a severe throbbing sensation in the head over the seat of the injury; tongue white and dry.V. S. ad 3x1.with further benefit.10th.Has been well purged; tongue clean, pulse more natural, eyes Oiuch depressed, the redness has left them, the fulness of head is also S?ne, and on the whole he is doing well.The discharge of a sanious Mature, the wound externally like ochre.In the afternoon the pulse rose, but was not so hard as to indicate the use of the lancet; has pain and Alness over the injury.Was purged with senna, &c. and after this had 110 further symptoms of consequence.He was discharged cured on the 23d of June.

" This case," says Mr. G. " shows the advantage to be obtained by removing sUch fractured and depressed portions of bone as might irritate t e dura mater and brain if allowed to remain, and also demonstrates the very great extent to Which blood may be drawn in strong and healthy persons, in a short period (160  in three days).When the symptoms were not so immediately urgent as to demand the use of the lancet, the free exhibition of drastic purgatives was attended by the best effect."* 109.

A want of method in Mr. Guthrie's writings, and an absence of logical Precision in his reasoning, render it not unfrequently difficult to determine exactly what he intends, or what cert in cases are meant to establish.5>ut we gather from some remarks upon the cases, that if the compound racture be attended with moderate depression, Mr. Guthrie would not attempt to elevate it, provided there were no urgent symptoms, whilst if .e thought there were pointed pieces projecting inwards, and likely to lrJitate the brain, he would elevate." If," he observes, " the examination ? the depressed part had led to the apprehensio that such points of bone 1(1 exist and were sticking into and irritating the dura mater or brain, I iould have removed them, under the belief that although they might not ^ the moment have given rise to any other symptoms than those which epended on the blow, the time would come when they would scarcely aJ1 to cause those which usually accompany the formation of matter Within the skull; or if this danger should also have been avoided, that the evils which have been noticed from p. 79 to 84 as occurring at a later Period, and which ultimately require the same operation for the relief of "e patient after months of acute suffering, might be encountered ; the cases^ at the pages indicated were referred to solely for the purpose of owing that, although a person might temporarily recover from an injury *> *?-' ~~i 7-7 ' 1 , Certain diseases give a peculiar tone to the circulatory system, enabling it infl ,ear' an<^ causi g it to require, great loss of blood in their treatment; they are animations of the serous membranes and parenchymatous substance of or- ?

Other diseases induce this effect in a much slighter degree; such are ?inflammations of the mucous membranes.Lastly, other diseases render the irr>eni unduly susceptible to the effects of loss of blood : these are the class of in liatl0Vs' as gastric and intestinal disorders and irritations.Dr. Marshall Hall "e Gulstonian Lectures for 1842.

[April 1 in which a portion of bone was allowed to remain an irritating substance to the brain, it did not follow that such recovery should be permanent.

If there be a doubt on the mind of the surgeon whether there are or are not any portions depressed and irritating the brain or its membranes, he should wait; and in this it is that the real difference between modern surgery and that of the olden time exists with respect to adults."We are not quite sure that th s is not better practice than trephining indiscriminately in every case of compound fracture with depression.

The following case supports, as far as one case can be considered to do so, this view.

Case.?" Captain R., aide-de-camp to General Sir L. Cole, received a wound from a musket-ball at the battle of Albuhera on the anterior and middle part of the left parietal bone at its junction with the rontal, which fractured it, causing some slight depression.He was rendered insensible at the moment, and was brought in the evening to the village of Valverde, where the insensibility was shortly followed by symptoms of inflammation, which were subdued by repeated bleed- ings, under which he gradually recovered, and remained well until killed at Pampeluna.The division of the scalp gave rise to no additional symptoms."

111.

Mr. Guthrie did not use the trephine, because the broken portions of bone did not on examination appear to press unequally on the dura mater, and it was presumed that the moderate degree of pressure which ensued from th depression might be borne with impunity, as it did not seem likely to be accompanied by the projection inwards of any pointed pieces which might irritate the brain.The result confirmed the supposition.

But the uncertainty that attaches to Mr. Guthrie's meaning will perhaps appear to others, as it does to us, from the passage which immediately follows the preceding.We supposed that Mr. Guthrie was treating of compound fracture with depression, that difficult and doubtful case in practice; yet the observations we shall quote seem to have reference to simple fracture.

" When a fracture is accompanied by depression, and the broken portion or portions of bone would seem to be driven into the dura mater or the rain, or to press so unequally upon them that as much mischief is likely to ensue fro? leaving, as from removing them, and especially in an adult or middle-aged man} less harm will in general follow from ascertaining the fact, by dividing the scalp> and removing the broken pieces, than by doing nothing, more particularly when the presence of a foreign body is ascertained.If there be no symptoms indica- tive of mischief below the fractured part, the surgeon must then decide, after the best estimate he is able to make of the probable evil which will occur from allowing the broken or depressed portions of bone to remain.I have already stated, page 104, that according to my experience an incision through the scalp renders the dura mater very little more liable to suppuration than it is without this; nevertheless that trifling degree of liability should not be incurred without an absolute necessity.I have now under my observation a child four years old who fell out of a window and has driven or bent in a portion of the frontal and parietal bones of the top of the head.The depression and fracture can be dis" tinctly felt, but as there are no symptoms indicating any immediate mischief) there can be no reason for interference.

" I have said, page 102, that in young persons the brain will bear a greater degree of pressure and of irritation with impunity than it will in persons oi mature ape, that by far the greater number of cases in which recovery has taken place after fracture and depression of the skull with injury of the brain, and even loss of its substance, have occurred in children or in persons under the adult age; greater reliance may therefore be placed on the powers of nature in them, and less frequent recourse .maybe had to the aid of operative surgery in order to prevent mischief than in adults, even when the bone is fractured as well as depressed. 112.Two cases are quoted, to be contrasted.The first was recorded in the Lancet, by Mr. Roberts, of Bangor.It was that of a little boy, in whom be allowed a large piece of bone to remain depressed and forced perpen- dicularly into the brain, and which appeared to him to be too firmly im- bedded in it to admit of extraction.Several portions of brain were lost or removed, the child suffered from convulsions, became paralytic on the opposite side to the injury, yet gradually recovered, three pieces of bone coming away in less than ten weeks.

The other case occurred to Mr. Liston.It was that of a boy eleven years of age, who had been thrown out of a cart eleven weeks before, and had his head cut in two places by a stone bottle.The wound on the anterior superior part of the head was the most serious, and from this an angular piece of the bottle was removed.He was insensible for one week after the accident, but gradually recovered, and could walk at the end of a month.

A few weeks afterwards he lost the power of speech for three days, which he recovered on a profuse discharge of matter taking place from the wound, togethe with vomiting.Three days after his admission into the University C llege Hospital, Mr. Liston examined the bone, and finding a fissure with some little depr ssion, he applied the trephine, when tvvo angular pieces of the inner table were found projecting much inwards ?n each side of the fissure, and were removed.The child did well.On these cases Mr. Guthrie remarks : " In the first there was opening sufficient to allow of a free discharge of matter as it was secreted, and for the removal of all irregular-shaped pieces of "pne.In the second the opening was not sufficient, and the irregular-shaped P'eces of bone could not be removed.In the first case the trephine was unne- cessary; in the second its use was imperatively called for, and it was suc- cessful."113.

Mr. Guthrie makes a remark which appears to us a very just and not an Unimportant one; it is this,?that the cases of recovery recorded bear a very deceptive proportion to the fatal cases that are not recorded.^Few relate an unsuccessful one, in which either the post-mortem examination proves that something has been overlooked, or that the injury was beyond remedy by any means at present known.This makes calculations founded upon published cases so fallacious.

. Some cases are given of fracture with depression and injury of the brain, ln which modes of practice of a very opposite character were attended with an equally successful result.Such are the circumstances which abound in medicine, and render it difficult to say what is and what is not right to be done.General rules must be charily laid down and cautiously <*cted on, experienc and judgment constantly stepping in to modify them.r.Guthrie's opinion is expressed decisively :?

The result of my experience has rendered it imperative in my mind t remove

[April 1 at once all portions of bone or foreign substances which may have or inay be supposed to have penetrated the dura mater in adults, although no symptoms of compression should be observed ; and generally in children, whenever it can be done without difficulty, and especially when symptoms of compression are present.

If the wound in the dura mater should not be sufficiently large to allow the offending body to e extracted through it, the opening must be increased to enable it to be withd awn without further laceration; and all substances which are irritating, or are likely to irritate the brain, should be removed in t e first instance, as I have already suggested, page 92, unless the attempt should be forbidden by the occurrence of convulsions, by the inability of the surgeon to seize the extraneous body, or by the evidence of the great suffering which it occasions; and all blood which may be extravasated should be carefully and lightly removed." 117.

It appears, then, that it is the probability of wound of the dura mater, that leads Mr. Guthrie to operate.But in compound fracture with de- pression, this probability must be a frequent one, and therefore we may presum

that the
peration will be a common one.In fact Mr. Guthrie's practice comes very nearly, after all, to Sir Astley Cooper's in this instance, while the former seems to advocate the use of the trephine in simple frac- ture with depression to an extent to which most surgeons are indisposed, perhaps, to go.But we repeat that the want of arrange ent in Mr. Guthrie's observations, and the mixing up of one subject with another, render it exceedingly difficult to say what his sentiments really are.

He goes on, for instance, to state :? " I have shown by the case of the soldier, p. 50, by that of Clayton, p. 70, of Capt.R., p. ill, and by others, that every depressed portion of bone accom- panied by fracture, and especially on the back part of the head, need not neces- sarily be removed.When the fractured and depressed bone is accompanied by symptoms of compression in an adult, which continue after the usual anti- phlogistic means arid remedies have been employed in vain, and appear to increase rather than to diminish, the broken and depressed portion should be raised; for although the brain will bear and accommodate itself to pressure in many persons in a manner which could not be either foreseen or expected, it will not do so in all; and the removal of the bone offers the best chance for relief, whether the mischief has arisen from the pressure made by it, or occurs from the extrava- sation of blood beneath.I have on several occasions found the principal symp- tom of compression to be a fixed pain in the part; and although the state of the fracture and depression would not alone have rendered the removal of the bone positively necessary, I did not hesitate about removing it when this symptom was present; and I have generally seen the pain subside after the operation.The case related by Mr. S. Cooper, to which I have referred, p. 78, is most useful, from the fact which followed the removal of the bone, viz.that the patient, who was before in nearly a lifeless state, instantly sat up in bed, looked around, and spoke rationally.There was scarcely one of those great battles or s

ges i
the Peninsula at which I was present, where a nearly analogous case did not occur.

" The greatest discrimination is required in cases where the extent of the injury is not so manifest, and in which there is more room for doubt.In most cases in which a slight or moderate degree of fracture and depression of the skull has taken place, the symptoms of concussion are present as well as those of com- pression.The symptoms of concussion are however coeval with the injury ; and although those of compression may take place almost instantaneously, they more usually occur at a later period of time.The symptoms of concussion may nevertheless continue for days, and more particularly the insensibility, or that

.state which is approaching to it, complicating the case and embarrassing the practitioner.In a child or young person the symptoms of compression or irri- tation, when they appear even at a secondary period, may pass away under fur- ther moderate depletion; hut in an adult any undue delay in giving the necessary relief hy the removal of the depressed portion of bone, will in general he de- structive to the patient.It is the irritation caused by the depressed bone on the dura mater, and communicated to the brain, which gives rise to the unfavourable symptoms, and to the formation of matter which follows." 119.

This s merely reverting to matters which had been treated of and settled long before.

But to proceed.Our author arrives at secondary formations of pus Mr. Guthrie touches on the formation of pus within the cranium by a sort of contre coup.

" When a very severe blow, accompanied by a shock, as from a fall, has been received on the head, and the skull is so thick and strong as to be able to resist the violence thus offered without being broken, or is only slightly fractured, the vibration or tremoussement is directly communicated to the brain, giving rise to laceration or bruising of its structure in various situations, to the rupture and separation of the vessels of the dura mater from the bone to which they are attached, and to derangement of other parts, which will in all probability be fol- lowed by inflammation, and may even terminate in the formation of matter under the dura mater as well as above it, and even in the brain itself.This is said to take place by ' contre coup' when it takes place in any ther part of the head than that which is struck, of which Mr. Shaw gives two cases : and of instances ?f which the older French authors are so profuse both in the explanation and in the fact.The cases related by Mr. Shaw are truly cases of laceration, the aecompaniment and the consequence of concussion of the brain, and were not felievable by the art of surgery; but they are not exactly what the older surgeons particularly distinguished as injuries by ' contre coup,' where the blow was on one ?1(le,and a fracture took place or matter was formed in a circumscribed spot on the other, which cases did sometimes, although rarely, admit of relief by ope- rative surgery." 120.

Mr. Guthrie, however, has not met with such cases unaccompanied by racture.Nobody at this time of day would dream of making an exploratory crusade with the trephine.

Mr. G. observes that, as all well-informed surgeons are aware, when the Periosteum covering the bone is bruised, or the bone is deprived of this niembrane, it does not follow that the bone should die or exfoliate.In ^any instances the wound will gradually close up and heal as i no such Occident had happened ; and in most cases this termination will only be delayed by the separation of a scale of bone from its outer surface.

Mr. G. passes on to suppuration n the dura mater, and " Pott's puffy Un3?r."

On this head Mr. Guthrie makes a remark which is not only,

)ye apprehend, true, but easily accounted for." Inflammation," he says, ?f the dura mater proceeding to suppuration or the formation of matter etween it and the bone, appears to have been a much more common con- Seciuence of injuries of the head in the time of Dease and Pott than at Present.I have rarely seen a case of the secondary tumor they have escribed, and on inquiring of the surgeons of the different hospitals in "Qndon who are on the Council of the College of Surgeons, consisting of v 'at may be called from their standing and position the elite of the '-Urgery of London, I find it is almost equally unknown to them."

Medico-ciiiuurgical eview.

[April 1

The fact is, that depletion and the influence of antimony and mercurv are now so freely resorted to, that inflammation does not run a-head as it was let do in the days of Pott.Mr. Guthrie dwells on the frequency with which suppuration on the dura mater is accompanied by suppuration on the surface or in the substance of the brain.

He says:?

" Suppuration, or the formation of pus on the surface of the dura mater, is not, then, under the strictly antiphlogistic system of the present day, a common occurrence; and sufficient attention is not therefore paid to the evil which fre- quently accompanied it in former times, viz.suppuration on the surface and in the substance of the brain itself?themore usual cause of death in all these cases of fracture and depression which are left to the ' chirurgie expectante,' or that which has been too long delayed.On referring to the records of sur ery from the earliest times unto the present moment, I find that the greater part of those who have died with fracture and depression of the skull, and whose cases are recorded, suffered from alteration of the structure or substance of the brain, and the for- mation of matter within it or upon its surface.I have seen and read of many cases of injury of the head without depression in which this termination ensued, as it might have done and has done from idiopathic inflammation without injury; but I firmly believe that it would not have taken place in a large proportion of those cases in which it occurred, if the present system of treatment had been pursued; or if the depressed bone had been raised to its level, and the irritation arising from undue or unequal pressure had been avoided.It must be admitted, however, that an internal part of the brain may receive such shock at the mo- ment of injury, as well as an external part, that no treatment can arrest its progress towards evil, although the mischief may be delayed; and when the patient dies after four, five, or more weeks of alternate hope and of suffering, matter is found in some part of the brain where an injury was not suspected."124.

Purulent matter may be de osited under, as on the dura mater, either in a circumscribed or in a diffused manner.The former may admit of hope?the latter scarcely can.Mr. G. touches on the incision of the dura mater, to evacuate blood or matter beneath it.He speaks favourably of the practice, which, however, is not to be lightly had recourse to.He says:?

" I have seen, on the removal of a portion of bone by the trephine, the duia mater rapidly rise up into the opening, so as to attain nearly the level of the sur- face of the skull, totally devoid, however, of that pulsatory motion which usually marks its healthy state; and an opening into it, under?these circumstances, has allowed a quantity of purulent matter to escape, proving that the unnatural elevation of the dura mater was caused by the resiliency of the brain when the opposing pressure of the cranium was remove .I consider this tense elevation and the absence of pulsation to be positive signs of there being a fluid beneath, requiring an incision into the dura mater for its evacuation.It is a point scarcely* if at all noticed in English surgery, although much insisted upon in France.It was not in the slightest degree understood at the commencement of the war if1 the Peninsula, and was one of those points which particularly attracted my attention."126.

Mr. G. relates several cases of an unsuccessful character?(thereare unhappily too many of them).We shall mention the heads of a successful one.

Mr. Guthrie operated in a case after the battle of Toulouse.The dura ater rose up into the trephine hole, without any pulsation.He punctured it, when a considerable quantity of pus oozed out.The opening was cn- larged, and the flow of matter was daily encouraged, until it gradually diminished, and ceased with the formation of granulations and the drawing in and cicatrisation of the part.

" Sir Astley Cooper entertained the opinion of Mr. Hunter, that a wound through the dura mater was particularly dangerous, in consequence of the tunica arach- noides which lines it being a serous membrane; and that, if the inflammation which ensued did not cease at the adhesive stage, by the consolidation of the surface which covered the pia mater with that which lined the dura mater, a dif- fused inflammation would necessarily follow, which might spread over its whole extent.

This theoretical opinion is fairly deduced from the state of analogous membranes, such as the pleura and peritoneum when wounded.I do not appre- hend however that practically the diffused inflammation is fo nd to occur in cases of injury of the head, so often as it might be expected; in consequence probably of the mor

equal
ressure that is kept up within the sk

l th
n in the chest or abdomen; but if wounding the dura mater be a danger that ought to be avoided, if possible, as one of great magnitude, the risk run by doing so cannot be put in comparison with that which accompanies the continuous irritation de- pending on the presence of a spiculum of bone, which has passed through the dura mater and is also irritating the brain beneath.Sir A. Cooper supposed that the danger would be diminished if the pia mater were wounded also, as th hrain would project and fill the wound; but I am not satisfied of the accuracy ?f this opinion; and if I had opened the dura mater through error or design, I should not think I had lessened the evil by adding to it a wound of the pia mater, and perhaps also of the brain." 128.

Mr. Guthrie turns to injuries of the brain, which, he observes, are less formidable to those accustome to military warfare, than to civilians who See them on a less frightful scale.

Gun-shot wounds of the skull are next treated of.Mr. G. recommends the external wound being in general enlarged by a simple incision, So as to show the extent of the depression or the size of the fragments.Where the bone is scarcely injured, or the periosteum only bruised, or pven where the bone is deprived of this, it does not necessarily follow that *t should die, or even exfoliate.In many ins ances, the wound will gra- dually close in and heal, as if no such evil had occurred; and in those "which do not terminate so favourably, the cure will only be delayed by the exfoliation of a layer or scale of bone from its outer surface, unless the mischief should have penetrated deeper, affecting the whole substance ?f the bone or even the parts beneath.

. " A musket-ball," continues Mr. G. " striking directly against a bone some- times makes a hole not larger than itself with or without any radiating fracture; and one trephine, if properly applied, will often embrace the whole of the mis- cmef, and admit of the removal of the broken pieces.The trephine should be ?t a large size, and as a centre pin cannot be used, it may be made to turn very well in most cases in a flat but thick bar of iron, having a hole in the middle of such size only as will admit the outside of the polished trephine to turn in it. 1ufficient support for the instrument will be obtained by this means until i has made a groove in the bone for itself, when the operation may be continued as it Would be in an ordinary case after the removal of the centre pin.Botal and  ercy both allude to contrivances of this kind as eminently useful, and I have Myself found it very advantageous.

?hen a musket-ball ranges along the side or top of the head, it may break e outer and depress and fracture the inner table to a considerable extent, for [April 1 the space even of three or more inches, of which the case related, page 105, is an example.I have almost always removed the broken portions of bone by means of good forceps and a straight saw, and have perhaps been as often suc- cessful as the reverse.I can see no reason for delaying the operation unless the case be doubtful, when it may be as well to wait for symptoms, as in the case above noticed.It sometimes although rarely occurs that a ball sticks so firmly in the bone that it cannot be extracted by working round it in an ordi

ry w
y, with a pointed instrument The diffi ulty usually arises from the ball having half buried itself in the diploe, and so little of it being exposed, as not to admit of a firm hold being taken of it.The large trephine, used in the way I have just pointed out, has enabled me several times to overcome the difficulty.I have even found the removal of the outer table to be sufficient where the inner one has not been driven into the dura mater; but where any doubt is entertained on this point the two should be removed." 131.

A ball, or other foreign substance, may penetrate the brain directly or obliquely.When directly, it can seldom be removed, and the patient rarely survives beyond two or three days.Mr G. has never had under his own care a case which did well after the removal of a ball, which had been deeply driven into the anterior part of the brain, though he has seen and mentioned several instances of recovery, w ere the injury had occurred towards the back part of the head, and the ball had been allowed to re- main.He thinks it " better in all such cases to allow the ball to remain, unmolested, which it will often do for many days, until circumstances ren- der it necessary to endeavour to find it.When it can be felt immediately under the surface, it ought to be removed as a foreign substance, provided this can be done with little apparent inconvenience.

Passing over some cases, we find Mr. Guthrie stating that when a ball strikes the head obliquely, it may enter and pass out, or lodge.Most of these patients die." When the entrance and exit of the ball are obvious and not far distant from each other, the splinters of bone should be re- moved ; and if the little bridge between the openings should be injured, the whole should be taken away by the straight saw ; an operatio which cannot however be necessary in the first instance, if the portion of bone should be apparently sound."

Perhaps the best case referred to is that of Baron Larrey, though it is probably too favourable a sample to be an ordinary one.

Case.?"A soldier of the 18th demi-brigade was wounded during the first re- volt at Cairo by a musket-ball, which pierced the middle of the frontal bone near the longitudinal sinus, without injuring the dura mater, and passed backward between it and the bone as far as the occipital suture.The accident was followed by the usual symptoms of compression, the soldier, however, always complaining of pain at the back part of the head at a spot opposite to the entrance of the ball.,I introduced a gum-elastic sound through the hole in the frontal bone, along the- track which the ball had made, until I discovered it by the resistance it.offeredto: the farther passage of the sound, and by the inequalities of its surface.Having thus ascertained the distance at which it was situated, I applied a large trephine immediately over the part by measurement; a quantity of pus was immediately evacuated, and I easily extracted the ball, which was depressing the dura mater and brain.The man after this recovered."133.

A case, in some degree, similar, occurred to Mr. Guthrie, but the brain was injured in front, and the man died.

Medico-ciiirurg cal Review.

[April 1 Case.?A soldier was wounded by a ball, which struck liira on the lower part of the right side of the forehead, fracturing the external wall of the frontal sinus.

On examination, the ball could be felt lodged in the sinus, from whence it was readily removed by enlarging the opening, and the man recovered without any bad symptoms.Le Dran gives a case in which a ball having entered in this way, was found a year afterwards lodged in the brain by the side of the sella turcica.

Mr. Guthrie has never seen a case in which, after wound of the frontal sinus, the air did more than raise the cicatrix, though he has often had difficulty in closing the external opening.

Mr. Guthrie relates some cases of injury of the brain, by foreign bodies which reached it through the orbit.Perhaps the following is as good an instance of the insidious and dangerous nature of these accidents as any.

Case.?" A boy, nine years of age, was brought to the Ophthalmic Hospital struck by his playfellow with the end of a thick iron wire on the right eye, which blackened it.There was no external wound; but as there was some bloody che- mosis at the upper part and inside, there was a probability of the wire having penetrated deeply, although the opening could not be discovered by the probe.The accident had happened two days before, and the boy had vomited shortly afterwards, and had eaten little since, although he did not think himself ill.He was well purged, and cold water was desired to e applied externally.Two days after he returned, complaining of sickness, headache, and some pain over the brow, and looked ill.It was now suspected that the instrument had penetrated into the brain, although the ecchymosis was in a great measure gone and the eye was unaffected.

He was bled freely from the temple of that side by leeches, and calomel and jalap were given him so as to act fully.He did not attend the next or fifth day, but on the sixth his mother came to say he had been very ill, and delirious and restless all night.On going to visit him, he was found stupe- fied, answering with difficulty and incoherently; pulse very quick, skin hot and dry, with some convulsive twitch s of the face and arms ; pupils slightly obeying the influence of a strong light, but not dilated.He was again bled freely from the temple, but his breathing became more difficult, he fell into a comatose state, and died in the night.On examining the head, the stiff iron wire was found to have passed under the upper eyelid between it and the eye, through the posterior part of the orbitar plate of the frontal bone and into the anterior lobe of the brain, which was softened at that part, and bedewed with a little matter."137.

Cases of this description, and they are not very rare, are calculated to inspire caution.It would have been well not to have suffered this boy to attend as an out patient.Had he been more closely watched, his chance might have been better.An injury of the longitudinal or lateral sinuses, which allows the blood to escape freely, is accompanied with little danger.But it is very fatal when the blood is permitted to accumulate.

Mr. G. makes some remarks on what is called fungus cerebri.It is of two kinds, and occurs at different periods of time.The first kind is principally composed of coagulated blood, usually appears immediately after, or within two days after the injury, and is generally fatal.The second takes place at a later period, and is formed for the most part of brain.They seldom occur either where the loss of skull has been great, or where, with a small opening, the dura mater is uninjured.

In the first kind of protrusion the dura mater must necessarily be torn 1843]

Mr. Gutlirie on Injuries of the Head.

to some extent, and the tumor which comes through it is of a dark brown colour, glazed and covered in general by the pia mater.These protrusions were accompanied, in the cases that Mr. G. has seen, by symptoms of inflammation of the brain and its membranes, coma not occurring till Eear the fatal termination.He has seen the protrusions torn off, and was able to satisfy himself " that they all arose from haemorrhage into the sub- stance of the brain, probably immediately below its surface, which became segmented in size as the inflammation proceeded, and was gradually protruded at the part where there was the least opposition.When the tumor "Was torn off little haemorrhage ensued, but a dark brown bloody cavity "Was seen in the substance of the brain; or when cut off and examined, the protruded part seemed to be covered by the pia mater, with or without a layer of cerebral matter, and was made up generally of coagulated blood."

Mr. G. never saw a case recover.He feels disposed to recommend that ' all such bloody tumors should be cut off" on a line with the surface of the skull as soon as they appear above it, or that they be removed alto- gether, so as t allow of a free discharge of blood or of vany fluid which may be collected under the dura mater.Blood cannot be drawn under these circumstances in any other way so well as from the surface or the sub- stance of the brain itself, and a free discharge for any matters which may he collected beneath the bone is essential to the safety of the patient."The general treatment should be that of inflammation of the brain, of which this must be looked on as a symptom.

In the second kind of protrusion, which occurs when the active inflam- matory symptoms are declining, Mr. G. is convinced that the tumor is tormed by the substance of the brain, though he is not convinced that the toss of brain is invariably proportionate to the extent of the protrusion.He thinks that as the precise quantity which a person may lose with impunity llas not been ascertained, it may be as well to deprive a patient of none, provided its removal can be dispensed with.In one of some cases the j^trate of silver was lightly used?moderate pressure is the remedy advised Mr. G.The pressure, he states, was graduated, according to the reeling of the individuals ; when made too firmly it gave rise to swimmings ^d pain in the head, retardation of the pulse, a sense of sickness and minting, and even in one instance to syncope.Pressure could only be borne when very lightly applied whilst the protrusion was increasing, but could be gradually augmented when it became stationary, and during its ^minution and secession.The pressure was continued until after the ^ound had healed.Mr. Guthrie observes :? " The preceding cases prove that persons may recover after having had a profusion of the brain, without, as well as with the loss of a portion of its sub- stance, the difference in all probability between the cases being dependent on e degree of mischief which gave rise to them.In all those which I had an opportunity of examining after death, and the injury in all was on the top or Pper part of the sides and back of the head, the protrusion was manifestly a liv*" the substance of the brain, and firmer than the hemisphere beneath, lat Was so^' Pu%> and ?f a yellow and sometimes of a reddish colour, the Q eral ventricle being filled with a sero-purulent matter, pus itself being spread the surface and intermingled with the pulpy structure, into which the brain a been changed.That the protrusion was the consequence of low inflamma- 0n of the brain, there could be no doubt; and that greater caution had been [April 1 necessary during the progress of the mischief than had been enforced, was in all probability the fact.It was the observation of this and of other circumstances not less important which led me to enjoin that rigid system of management which I have insisted upon in all cases of injury of the head.There can be no doubt of the formation of many of these protrusions being aided by the opening which has been made in the dura mater, which would have restrained their growth if it had been sound.The dura mater should never therefore be opened if it c n be avoided, and the protrusions thus formed are the most likely to b withdrawn as the irritation which gave rise to them subsides."144.

Mr. Guthrie, like most modern surgeons, is averse to excision.There are some remarks on abscess of t